Rev. Soc. Bras. Med. Trop. vol.50 número5

Images in Infectious Diseases

Dengue fever with thrombocytopenia

and gingival bleeding

Fred Bernardes Filho

_{, Caio Cavalcante Machado}

and Andreia de Oliveira Alves

[1]. Divisão de Dermatologia, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil.

[2]. Departamento de Emergência, Hospital Imaculada Conceição da Sociedade Portuguesa de Beneicência, Ribeirão Preto, SP, Brasil.

[3]. Divisão de Reumatologia, Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brasil. [4]. Faculdade de Medicina, Centro Universitário Barão de Mauá, Ribeirão Preto, SP, Brasil.

A 45-year-old man was admitted on the sixth day owing to classic dengue symptoms that included spontaneous bleeding from the gums and a purpuric rash. His white blood cell count on admission was 3.1 × 103_{/µL with a low platelet count of}

2,000. On physical examination, gingival bleeding, scattered petechiae, and ecchymoses were observed (Figures 1A, 1B, 1C and 1D). Results of cardiorespiratory, gastrointestinal, and neurological examinations were normal. Chest radiography showed no pleural effusion and an abdominal ultrasound showed

no free luid in the cavity. The lowest platelet count (1.0 × 103_/

µL) was reported from the seventh to ninth day of the illness. Laboratory tests revealed positivity for immunoglobulin M (IgM) antibodies to dengue virus. Subsequently, treatment for thrombocytopenic purpura due to dengue was initiated. Hydrocortisone 500mg/day was administered intravenously for 6 days, and, prednisone 20mg/day, for an additional 10 days.

Two days after initiating treatment, the bleeding stopped, and by

the ninth day post-treatment, platelet count increased to 30,000 cells/mm3. The patient’s hospital course was uncomplicated, he

remained clinically well, and he was discharged with instructions to return for follow-up in the outpatient clinic. No spontaneous hemorrhagic events have occurred since, and platelet counts have remained within normal levels (Figure 2 and Figure 3).

Acute immune thrombocytopenia can be linked to underlying conditions like connective tissue disease, lymphoproliferative

disease, immune-deicient states, and viral infections, or to

medications administered1-3. Thrombocytopenia associated with

viral infection results from both lowered platelet production from megakaryocytes, and decrease in platelet half-life.

Conlict of interest

The authors declare that there is no conlict of interest.

FIGURE 1 - Dengue fever. A: Acute gingival bleeding (white arrows).

B: Scattered ecchymoses and petechiae. C: Hematoma on the left arm after

blood pressure cuff inlation. D: Multiple ecchymoses on the right arm.

Corresponding author:Dr. Fred Bernardes Filho.

e-mail: f9ilho@gmail.com Received 30 June 2016

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Bernardes Filho F et al - Dengue fever

FIGURE 3 - Disappearance of the hematoma as observed at the inal

follow-up.

REFERENCES

1. Cines DB, Blanchette VS. Immune thrombocytopenic purpura. N Engl J Med 2002;346(13):995-1008.

2. Kumar S, Khadwal A, Verma S, Singhi SC. Immune thrombocytopenic purpura due to mixed viral infections. Indian J Pediatr. 2013;80(5):421-2.

3. Fonseca T, Segarra-Torres A, Jaume-Anselmi F, Ramírez-Rivera J. Dengue fever: a rare cause of immune thrombocytopenia. Bol Asoc Med P R 2015;107(2):51-3.

160,000

Started of the gingival bleeding

Bleeding stopped

Hospital discharge

140,000

120,000

100,000

80,000

60,000

40,000

20,000

0,000

2,000

1,000 1,000 1,000

30,000

Platelets Days of illness

138,000

0 2 5 6 7 8 9 10 11 12 13 14 15 16 18 20 21 24 27 30 42

Platelet count